Social Stigma May Negatively Impact Treatment Adherence in Schizophrenia

Schizophrenia was perceived as more distressful and with higher perceived social stigma than other disorders.

Poor adherence to antipsychotic treatment in schizophrenia may be attributable to socially negative representations of schizophrenia, according to a new German study.

A team of researchers headed by Fabrice Berna of the University Medical Center Hamburg-Eppendorf, department of psychiatry and psychotherapy, Hamburg, Germany, conducted a Web-based survey of 1807 healthy participants, who were asked to imagine that they had a particular chronic illness based on clinical vignettes. The researchers focused on mental (schizophrenia or recurrent depression [RD]) and somatic illnesses (rheumatoid arthritis [RA] or multiple sclerosis [MS]).

Participants were asked to rate their subjective distress and perceived social stigma associated with each illness, the treatability of the illness, their belief in the effectiveness of treatment, and their treatment preference regarding medication.

Each participant was presented with a comparison between one mental illness and one somatic illness, and each illness was presented 4 times, portraying different levels of illness severity, so each participant was presented with 8 clinical vignettes.

At the beginning of the study, participants were told that the researchers were “interested in investigating how people would behave if they suffered from chronic illnesses,” and told that they would be presented with 8 short vignettes and asked to imagine that they personally suffered from that particular illness, how much of a burden it would be (eg, impairment in daily life and feeling of threat, being avoided by others), which treatment option the participant would prefer (oral medication, long-acting injection [LAI] of the medication; alternative medicine, such as acupuncture, psychotherapy, spiritual/religious approaches; or no treatment, and whether the treatment options were effective.

The researchers found that greater illness severity was associated with greater distress and perceived social stigma, and lower treatability (P <0.001 for all measures; 0.015 <ηp2s <0 .28). The main effect of illness severity was more pronounced for mental than for somatic conditions in perceived social stigma and treatability (P <0.05 for all measures; 0.003 <ηp2s <0 .006).

Mental illness was considered more distressful and less treatable than somatic illness, and schizophrenia was considered to be more distressful than RD (P <0.001; ηp2s =0.73). Significantly higher scores of perceived social stigma were found in mental than in somatic illnesses (P <0.001; ηp2s =0.43), with schizophrenia higher than RD (P <0.001; ηp2s =0.05).

Participants were less prone to choose medication for treating mental illness than somatic illness, and more likely to choose medication for RD than for schizophrenia (Ps <0.01, .0.01 ≤ ηp2s <0.155). And when the illness was named, mental illnesses were associated with greater distress than somatic illness, but the percentage of participants who switched from no medication to medication was much higher (70.4%) than that of participants who switched from medication to no medication (29.6%).

The researchers comment that their results “uncovered critical attitudes towards mental illnesses and their prevalent treatment that are not confined to patients who have been diagnosed with mental illness but shared by most people.” These “socially shared attitudes” may explain why medication for mental illness is less preferred than medication for chronic somatic illnesses. However, contrary to the researchers’ predictions, naming mental illness did not affect the perceived treatability of illnesses and even increased the decision to take medication.

All of the chronic illnesses included in the study are associated with substantial burden, and characterized by poor prognosis and social stigma, the investigators noted. However, schizophrenia was perceived as more distressful and with a higher perceived social stigma than all the other disorders. Medication for schizophrenia was regarded as less efficient and less preferable for treating schizophrenia than for treating other diseases.

The researchers suggest that their findings may “reflect negative attitudes towards psychotropic drugs that have already been shown in other studies.” They express the hope that their findings will “prevent clinicians from jumping to a simplistic conclusion that nonadherence to antipsychotics is explained only by factors specific to the (“unthankful” and nonconformist) patient or the disorder itself.”